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.4 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />\01\\ 304 E. Weber, Third Floor, Stockton, CA., 95202 cy"ck <br />(209) 468-3449 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with <br />San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. <br />TI-I oRrvi,>n Ar) p Assessor's WELL LocationLin CAP/ t 4 L Avc • Zip 9 5,, Parcel# 05 5- 3 2 Cross Street 4-6Pl'-i A k/K City o a. <br />WORK TO BE PERFORMED <br />UNIT IV <br />PROPERTY Owner Riad4/6) bc-_,K1.0z) Address (04 ) C0 ,4 i4L ikk! • City 6- 00 ii_ Zip952a Phone#(Zc-15 ) 3b -7- 9 3Z3 (-) <br />C-57 Contractor A , G., a <br />P C, c i <br />Address 33) c fAt'irg" <br /> <br />, vt,c -I Consultant/ Sub Contractor , <br />City rwia nti,r\ Zip9 ZG Lic# 656a2 7 Phonei7/ 0 9 9(.; 5 /E.L, <br />Address 00C: /‘,/, k/Q: Ik=f', City 37-:,-K Mr', Lic# 6 br: Z:Z 7 Phone4(Zu() )1 L 7 /,- c ), <br />GIS Coordinates: X y Township 3R) Range 5 r-_-__ , Section i y <br />X NEW WELL / BORING ( CPT OIL <br />0 WELL # <br />TYPE OF WELL <br />COMMENTS: <br />INSTALLATION TYPE <br /> <br />Avcr‘cQ 0-1 ro 5 P <br />0 MONITORING 0 HOLLOW STEM <br /> <br />EXTRACTION <br />0 AIR HAMMER/DRIVEN <br />0 VAPOR <br />MUD ROTARY <br />0 AIR SPARGE />USH POINT <br /> <br />)OIL BORING 0 HAND AUGER <br />0 OTHER: 0 OTHER <br />DESTRUCTION (choose type below) <br />CONSTRUCTION SPECIFICATIONS <br />DIA. OF BOREHOLE a' MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA:1\-)10 <br />65(r r coi/tLi-ro,r) <br /> <br />O OVER-BORE <br />0 PRESSURE GROUT t <br />CASING THICKNESS kJ/0- TYPE OF CASING: 0 STEEL 0 PVC 0 OTHER: N./a <br />DEPTH OF GROUT SEAL .7'nt 1 TREMIE TYPE TO BE USED: 0 AUGERS ›iff-IOSE <br />GROUT SEAL PUMPED: 0 Yes *lo (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br />APPROX. BORING DEPTH 5 k 6 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br />CONDUCTOR CASING PROPOSED? ( if YES, list specifications here): <br />GEOPROBE, <br />1NG# - -‘5 'lip-IZ, <br />HYDRIRPUNrIHND-AliRER, 9THER*1 <br />r I r <br />*Other: <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules <br />and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sub-contracting signature certifies the following: "/ certify that in the performance of the work for which this permit is issued, I shall employ persons subject to WORKERS' COMPENSATION Laws of California." <br />JHE APPLICANT MUST CALL 48 WORKING HRS IN ApyANCE FOR ALL REQUIRED INSPECTIONS. <br />Signed x(7 Title I CcPoi (y/Date o 9/ c 0 <br />SEE SITE MA IN UNIT IV WORK PLAN DATED: Niaqiqq <br />DEPARTMENT USE ONLY <br />Date Issued — I 3-06 Area 06;1 ir,?.(71 <br />Final Inspection By <br />ACCOUNTING ONLY: AID# <br />FAC# <br />PE CODES FEE INFO AMOUNT REMITTED CHECK # REC'D BY DATE ---", r RE• . - T# INVOICE <br />S 50 1 gib C6 P) ?:r /3(tle7 °I1A 3-1 ° ( S R# /,‘, Z-2-1 t" C '7 T Tr,C/kTC1-71-1 ,r, ,-.1. T.,- v. • ..,...... .-. . •-• ..-.... - - - - - _ _ <br />Application Accepted By <br />Grout Inspection By <br />Destruction Inspection By <br />COMMENTS / CONDITIONS: <br />Date <br />Date <br /> <br />- RKERS' <br />UNIT IV - 6/23/99 /sign bkpg/MI <br />er • LARATION